At approximately 10:19 a.m. on Aug. 5, 2010, EMS units from Meramec (Mo.) Ambulance District and fire/rescue units from Boles Fire Protection District (FPD) were dispatched to a crash on I-44 in the area of Gray Summit, Mo., 42 miles southwest of St. Louis. The initial response consisted of two ALS EMS units and one EMS officer from Meramec Ambulance District, two fire-rescue units and a fire officer from Boles FPD, and officers from the Missouri State Highway Patrol and Franklin County Sheriff.

As the initial EMS units approached the incident, they reported that a truck tractor (without a trailer) and two school buses had been involved in the crash. A mass casualty incident (MCI) Level 1 response, which instructs the dispatcher what equipment is needed, was initiated.

Crash Details
The first bus involved in the crash (bus 1) had run into the rear of a truck tractor, and the second bus (bus 2) had crashed into the rear of bus 1. Boles FPD units requested additional fire apparatus and reported that there was an additional vehicle trapped under bus 1 and multiple extrications would be necessary. Because helicopter services reported a 24-minute estimated time of arrival, they weren’t utilized. However, a motor coach tour bus company was contacted to provide a bus for shelter and transport, and it arrived in 50 minutes.

Upon arriving at the scene, providers observed patients extricating themselves from bus 2 and walking down an embankment to a nearby frontage road. In bus 1, patients were moving around inside the bus but were unable to exit due to severe damage to the rear of the bus. Command was promptly established and triage and transport operations were started. Initial triage was set up on the frontage road where the bus occupants had been congregating. Fire-rescue units placed a ladder against the side of bus 1 to extricate patients.

Patient Classification
It was determined that there were 58 total patients involved in the MCI:
• 54 students (one deceased in bus 1);
• Two bus drivers;
• One truck tractor driver; and
• One deceased driver of the pickup under bus 1.

Meramec Ambulance used the Simple Triage and Rapid Treatment (START) triage system to classify patients: two “red,” 19 “yellow,” 35 “green” and two deceased.

As other EMS units arrived, the red and yellow patients were transported to medical facilities. The green patients were moved onto the motor coach tour bus for reassessment and eventual transport. Total time until all patients were transported was one hour and 58 minutes. Overall, 28 EMS providers, 18 fire personnel and five auxiliary fire personnel from seven EMS and three fire-rescue agencies participated.

Lessons Learned
Christine Neal, chief of the Meramec Ambulance District, shared her observations and lessons learned about the incident.

Access Issues: Incidents such as this one often present access problems. For example, the highway was closed just moments after the crash and traffic in both directions became gridlocked. To complicate matters, the highway is divided by a cable barrier and access was limited at the crash location, which was located between two exit/entrance ramps four miles apart. Also, the perimeter road was used by most of the responding EMS units because patients had congregated there. This choice of EMS operation location prevented undue delays in getting resources on the scene.

Bystander Assistance: With MCIs like this one, bystanders will often offer assistance. Meramec Ambulance District personnel used this to their advantage. For example, two clergymen provided emotional support to many patients. Due to the heat, other bystanders provided water for patients who had no medical contraindications to being given water.

Transport: We often hear in MCI training classes that we should consider using alternate means, such as buses, to transport green patients. Buses can also be used on scene as shelter for patients and rescuers. Although Meramec Ambulance District had utilized a local motor coach tour bus for shelter in the past, this was the first time they used a bus for transport. Neal wisely chose not to use school buses for this. Although the local school bus company offered buses, they aren’t air conditioned. Also, EMS providers felt that some students may have been uncomfortable re-entering a school bus just after the crash. So the air-conditioned tour bus was chosen instead. Due to the large number of green patients and the lengthy return time for the units transporting to St. Louis hospitals, the decision was made to transport the green patients on the tour bus with a paramedic on board.

Hospital Utilization: There are two pediatric Level 1 trauma centers in St. Louis. EMS dispatch communicated with the hospitals to advise them of the MCI. Command’s initial plan was to divide the patients between each facility, but one hospital (St. Louis Cardinal Glennon) said they’d accept all the green patients. Command personnel were surprised by this, and questioned the idea, but the hospital trauma coordinator explained that at the time of the MCI, they were having their emergency nurse and physician meeting. They adjourned the meetings and staffed the emergency department to accommodate the patients. This allowed all 35 green patients to be transported in one bus.

Patient Accountability & Tracking: Despite the fact that Meramec Ambulance District had a command system in place, they encountered some challenges with patient tracking and accountability. This is common at such a scene. To complicate matters further, many students had cell phones and were calling or texting friends and family, as well as photographing the scene. As a result, some family members and friends arrived on scene. There were instances in which multiple family members were involved in the crash, which led to patients searching for their siblings. However, most of the patients were tracked well throughout the incident because they were older teenagers and could comply with EMS instructions to remain in triage areas.

Improvement Areas
Although there were many successes at this MCI, Neal also shared several observations about potential improvement areas.

Incident Command: EMS operations were controlled by a formal incident command system. The department carries MCI command kits in a number of its vehicles. These kits contain specific materials such as checklists, command vests and triage supplies. Although staff had trained with the kits and some of the contents were appropriately used, Neal states that command personnel could have better utilized these supplies.

As is common with MCIs, due to the limited number of providers initially on the scene, some command positions were combined. For example, one person was initially assigned to supervise both triage and transport. In smaller MCIs, combining positions for the duration of the incident is a viable option. Neal says separating these positions would have been beneficial.

Triage: Although formal triage was performed, and although tags were available, the tags weren’t placed on the patients. This resulted in some patients being triaged twice, as well as some general confusion about who had been triaged. Neal says they plan to ensure triage tags are used at any similar incident in the future.

Communications: In the area in which the incident took place, most fire and EMS agencies are separate, and dispatch is handled by several different agencies. For this reason, common radio channels exist for multi-agency operations. However, they didn’t break the incident out onto different channels for use by various groups and divisions, and some confusion ensued. Meramec Ambulance plans to address this earlier at any future events.

Conclusion
Whenever an MCI involves a large number of children, and especially when fatalities are involved, it’s easy to become distracted and feel overwhelmed. Thanks to preplanning, training and preparation, the Meramec Ambulance District EMS providers and surrounding EMS and fire-rescue agencies were able to effectively manage the challenges faced with this MCI.

Daniel Mack, NREMT-Pis assistant chief of Miami Township Fire & EMS, Cincinnati, and a member of the Cincinnati area UASI group and Hamilton County USAR Team. He can be contacted at danmack2@yahoo.com.